617297
case-report2015
JPCXXX10.1177/2150131915617297Journal of Primary Care & Community HealthDoyle et al
Case Studies
Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists
Journal of Primary Care & Community Health 2016, Vol. 7(2) 118–121 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131915617297 jpc.sagepub.com
Daniel Doyle1,2, Mary Emmett3, Amber Crist1, Craig Robinson1, and Michael Grome4
Abstract Background: Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care. Purpose: To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists. Methods: During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications. Results: Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications. Conclusions: A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients. Keywords dual eligible, quality improvement, care coordinator, clinical pharmacist, community health center, primary care, rural, Medicare, Medicaid, polypharmacy, Beers list
Introduction There are 9.6 million dual eligible persons in the United States; 82 000 in West Virginia.1 These patients are disabled, poorer, sicker, more likely to be disabled, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole.1,2 They consume 1.7 their per capita share of Medicare and 2.6 of Medicaid resources.3-5 The total cost of their care was $319.5 billion in 2011.2 Medical care for dual eligible patients is often substandard and fragmented. This is partly due to the conflicting rules and incentives of the Medicare and Medicaid programs each of which pays for different parts of dual eligibles’ care.2
A network of federally qualified health centers (FQHCs) and a tertiary care referral hospital in southern West Virginia undertook a care coordination project for a sample of their dual eligible patients. The partners had more than 10 years 1
Cabin Creek Health System, Dawes, WV, USA New River Health Association, Scarbro, WV, USA 3 Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA 4 Southern West Virginia Health System, Hamlin, WV, USA 2
Corresponding Author: Daniel Doyle, Cabin Creek Health System, New River Health Association, PO Box 70, Dawes, WV 25054, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at Bobst Library, New York University on March 16, 2016
119
Doyle et al of experience working together to improve the care of highrisk populations including those with no insurance, frail elder status, disability, chronic obstructive pulmonary disease, and black lung.
Methods Setting The partners in this project included 3 participating FQHCs with a combined 50 000 users and 190 000 patient encounters in 2011. The tertiary care referral hospital had 800 beds with more than 40 000 inpatient discharges and 560 000 outpatient visits in 2011. These partners held a series of facilitated meetings during 2011 to develop a plan for coordinating the care of high-risk populations with multiple chronic conditions. A decision was made to focus on the dual eligible population. A care model was developed based on the strategy of “a triple arrow for the triple aim”.6 The “triple arrow” was “relationships, transitions, medications.”
Patient Selection Each FQHC was asked to recruit 200 dual eligible patients. This was a purposeful convenience sample. Lists were generated by identifying eligible patients in a serial manner until the number 200 was reached. Site 3 only identified 156 patients.
The Care Model Relationships. The “relationships” part of this model posited that a close relationship with extra communication and advocacy would better serve the needs of high-risk patients. The use of care coordinators was already established, to varying degrees, in the 3 participating FQHCs. Each practice assigned at least 0.5 FTE (full-time equivalent) care coordinator to its dual eligible patients selected for participation. The care coordinator conducted a structured review of the medical record, an in-person “welcome interview”, and regular telephone contact on an as-needed basis with each patient throughout the 2012 intervention period. The care coordinator brokered optimal access and 2-way communication between the patients and the primary care team in the FQHC. Transitions. Care coordinators were to review daily notifications of hospital admissions and emergency room (ER) visits and to contact the patient within 2 working days. They discussed discharge medications, follow-up appointments, and answered questions. They communicated unmet needs to the primary care team and made referrals to community resources. Medications. The prevalence of polypharmacy7 and the use of potentially inappropriate medications8-10 are well
documented in US chronic disease and elderly populations. Clinical pharmacists conducted drug utilization reviews (DURs) starting with patients on 15 or more medications. Criteria used in this DUR process included the validated STOPP and START criteria7 and, for patients older than 65 years, the Beers list of potentially harmful medications.8 The completed DURs were provided to the patient’s primary care provider with follow-up discussions and assistance to make indicated changes in medication regimens.
Data and Analysis A set of baseline and outcome measures along with scannable data collection instruments were developed as part of this quality improvement project. The data forms completed by the care coordinators were collected and scanned to a database at the research institute of the main referral hospital. Hospitalization and ER utilization data were obtained from the referral hospital admissions data base with comparisons of the intervention year 2012 to the previous year of 2011. Medication lists were audited before and 3 to 4 months after the clinical pharmacists’ DUR. All data were cleaned prior to performing analysis. Descriptive statistics, t test, chi-square, Fisher’s exact test, and McNemar test were used where deemed appropriate in presentation of data in the exhibits. A value is considered significant with a P value of
case-report2015
JPCXXX10.1177/2150131915617297Journal of Primary Care & Community HealthDoyle et al
Case Studies
Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists
Journal of Primary Care & Community Health 2016, Vol. 7(2) 118–121 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131915617297 jpc.sagepub.com
Daniel Doyle1,2, Mary Emmett3, Amber Crist1, Craig Robinson1, and Michael Grome4
Abstract Background: Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care. Purpose: To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists. Methods: During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications. Results: Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications. Conclusions: A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients. Keywords dual eligible, quality improvement, care coordinator, clinical pharmacist, community health center, primary care, rural, Medicare, Medicaid, polypharmacy, Beers list
Introduction There are 9.6 million dual eligible persons in the United States; 82 000 in West Virginia.1 These patients are disabled, poorer, sicker, more likely to be disabled, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole.1,2 They consume 1.7 their per capita share of Medicare and 2.6 of Medicaid resources.3-5 The total cost of their care was $319.5 billion in 2011.2 Medical care for dual eligible patients is often substandard and fragmented. This is partly due to the conflicting rules and incentives of the Medicare and Medicaid programs each of which pays for different parts of dual eligibles’ care.2
A network of federally qualified health centers (FQHCs) and a tertiary care referral hospital in southern West Virginia undertook a care coordination project for a sample of their dual eligible patients. The partners had more than 10 years 1
Cabin Creek Health System, Dawes, WV, USA New River Health Association, Scarbro, WV, USA 3 Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA 4 Southern West Virginia Health System, Hamlin, WV, USA 2
Corresponding Author: Daniel Doyle, Cabin Creek Health System, New River Health Association, PO Box 70, Dawes, WV 25054, USA. Email: [email protected]
Downloaded from jpc.sagepub.com at Bobst Library, New York University on March 16, 2016
119
Doyle et al of experience working together to improve the care of highrisk populations including those with no insurance, frail elder status, disability, chronic obstructive pulmonary disease, and black lung.
Methods Setting The partners in this project included 3 participating FQHCs with a combined 50 000 users and 190 000 patient encounters in 2011. The tertiary care referral hospital had 800 beds with more than 40 000 inpatient discharges and 560 000 outpatient visits in 2011. These partners held a series of facilitated meetings during 2011 to develop a plan for coordinating the care of high-risk populations with multiple chronic conditions. A decision was made to focus on the dual eligible population. A care model was developed based on the strategy of “a triple arrow for the triple aim”.6 The “triple arrow” was “relationships, transitions, medications.”
Patient Selection Each FQHC was asked to recruit 200 dual eligible patients. This was a purposeful convenience sample. Lists were generated by identifying eligible patients in a serial manner until the number 200 was reached. Site 3 only identified 156 patients.
The Care Model Relationships. The “relationships” part of this model posited that a close relationship with extra communication and advocacy would better serve the needs of high-risk patients. The use of care coordinators was already established, to varying degrees, in the 3 participating FQHCs. Each practice assigned at least 0.5 FTE (full-time equivalent) care coordinator to its dual eligible patients selected for participation. The care coordinator conducted a structured review of the medical record, an in-person “welcome interview”, and regular telephone contact on an as-needed basis with each patient throughout the 2012 intervention period. The care coordinator brokered optimal access and 2-way communication between the patients and the primary care team in the FQHC. Transitions. Care coordinators were to review daily notifications of hospital admissions and emergency room (ER) visits and to contact the patient within 2 working days. They discussed discharge medications, follow-up appointments, and answered questions. They communicated unmet needs to the primary care team and made referrals to community resources. Medications. The prevalence of polypharmacy7 and the use of potentially inappropriate medications8-10 are well
documented in US chronic disease and elderly populations. Clinical pharmacists conducted drug utilization reviews (DURs) starting with patients on 15 or more medications. Criteria used in this DUR process included the validated STOPP and START criteria7 and, for patients older than 65 years, the Beers list of potentially harmful medications.8 The completed DURs were provided to the patient’s primary care provider with follow-up discussions and assistance to make indicated changes in medication regimens.
Data and Analysis A set of baseline and outcome measures along with scannable data collection instruments were developed as part of this quality improvement project. The data forms completed by the care coordinators were collected and scanned to a database at the research institute of the main referral hospital. Hospitalization and ER utilization data were obtained from the referral hospital admissions data base with comparisons of the intervention year 2012 to the previous year of 2011. Medication lists were audited before and 3 to 4 months after the clinical pharmacists’ DUR. All data were cleaned prior to performing analysis. Descriptive statistics, t test, chi-square, Fisher’s exact test, and McNemar test were used where deemed appropriate in presentation of data in the exhibits. A value is considered significant with a P value of
